Station - QSEN



|[pic] |ADVANCED Pharmacology in Nursing Practice |

| |Competency Exam |

| | |

| |Diabetes/Insulin/Steroids |

| | |

| |Case Materials – Evaluator Copy |

Station IV, Room G200

Actor: (Teaching Assistant/Faculty) goes on about being diligent in care of self with DM, certain that the glucometer is not functioning properly.

Station Set-up:

1. Reference books: Lab book, Med/Surg textbook

2. One-Touch glucometer (patient brought it in with her to get it checked out because value off the wall)

3. Regular and NPH insulin vials (2 vials each, making sure correctly labeled and NPH is cloudy)

4. Insulin syringes (X 20)

5. Medication bottle with patient label for Prednisone with Prednisone pack (written on paper)

6. Alcohol swaps (1 box)

7. 2 X 2 gauze pads (1 box)

8. injecta pad

9. Patient chart with doctor’s orders includes sliding scale and glucose recording chart.

10. MAR with sliding scale

Setting: Home visit

Case:

You are the registered nurse making a home visit with Mrs. Peggie Raines. She is a middle-aged, obese, jovial woman. She is IDDM, onset 7 years ago and was not initially well controlled and thus you have standing orders for sliding scale insulin. Over the past 6 months she has been well controlled. Her favorite pastime is working in the garden; about two weeks ago contracted severe poison ivy, started on Prednisone 9 days ago. Her blood sugar at home was greater than 300, because it did not register on One-Touch glucometer. It stated >300. She wonders if her blood sugar machine is malfunctioning since her glucose levels have been normal for quite some time now. She has had a terrible itch but it is somewhat better now. You perform a finger stick using the glucometer you brought with you (you calibrated it this am). The glucometer reading per your machine is 360; so, do you administer insulin, if so how much? It is assumed you have washed your hands.

Student Expectations

Cognitive:

1. Why is the glucose level high currently? (Due to administration of Prednisone. Prednisone is synthetic hormone/adrenal corticosteroid. In the body, the adrenal glands secrete various hormones such as glucocorticoids, mineralcorticoids, as well as androgens and estrogens. Glucocorticoids have metabolic (increase in blood sugar by promoting gluconeogenesis in liver and decreasing use of glucose in muscle), anti-inflammatory (suppression of T-lymphocytes, natural killer cell activity), and growth-suppressing effects. The synthetic prednisone is mimicking these actions, therefore, raising the pt’s glucose readings)

Skill:

1. 5 RIGHTS including 3 checks, 2 patient checks, 3 meds checks check to see if the patient has any known allergies

2. Reviews labs

3. Selection and administration of correct insulin.

4. Using surgical asepsis, administers ____ units of Regular insulin

Sliding Scale for Insulin

>400BS               15U Reg

399 – 350 BS         10U Reg

349 - 300 BS 7 U Reg

299-250 BS 4 U Reg

249 - 200 BS               2U  Reg

Less than 200=Do nothing

To check ac and hs

Or you can calculate it.

Blood Sugar - 120  = Regular Insulin Dose

30

Subcutaneous Injection Procedure

           

Administering subcutaneous injections

Determines needle size appropriate for med, site of injection, and patient's body composition

Dons clean gloves

For insulin administration, uses an insulin syringe (30u, 50u, 100u syringe) that corresponds with available insulin strength

Identifies area for injection that has at least a 1-inch fat fold

For heparin administration, chooses site at least 1" below umbilicus in lower abdominal fat pad, above level of iliac crests

For insulin administration, chooses non-muscular flabby site: posterior upper arms, abdomen (1" away from umbilicus), above scapulae, buttocks, upper outer thigh

Cleanses skin with antiseptic in a circular motion moving outward, and allows to dry

Pinches skin to elevate tissue as necessary

Uses a dartlike action to insert needle at a 45-90 degree angle, depending on patient's body composition

Injects med slowly

Removes needle without traumatizing tissue

Wipes injection site gently (avoids massage) with gauze pad after removing needle

For heparin administration, alternates site of injection

For insulin administration, rotates sites on a predetermined rotation schedule

Comments: Medications given SQ primarily include heparin and insulin. Maximum amount in one site is 1 cc (adults). Note that aspirating to check for blood return and massage after SQ injection are NOT preferred techniques and could be unsafe, especially when giving heparin. This is controversial, your text recommends aspirating for insulin. Check with your clinical faculty as to their preference.

To prepare two insulins in the same syringe:

- into longer-acting insulin vial (NPH cloudy), inject amount of air equal to volume that will be aspirated (without touching needle to insulin)

- withdraw needle

- into shorter-acting insulin vial (Regular clear), inject amount of air equal to volume of insulin that will be aspirated and withdraw insulin

- withdraw needle

- change needle

- insert needle into longer-acting insulin vial and withdraw insulin

An alternate technique involves drawing up insulins in separate syringes, one syringe having a volume capacity to accommodate both insulins. Follow with injecting insulin from one syringe into the other (larger) syringe.

Many agencies now have a combination formula containing short acting and long-acting insulin.

Advanced Pharmacy Competency Exam

Station IV, Room G200

Scenario Handout

Setting: Home visit

Case:

You are the registered nurse making a home visit with Mrs. __________________

She is a middle-aged, obese, jovial woman. She is IDDM, onset 7 years ago and was not initially well controlled and thus you have standing orders for sliding scale insulin. Over the past 6 months she has been well controlled. Her favorite pastime is working in the garden; about two weeks ago contracted severe poison ivy, started on Prednisone 9 days ago. Her blood sugar at home was greater than 300, because it did not register on One-Touch glucometer. It stated >300. She wonders if her blood sugar machine is malfunctioning because her glucose levels have been normal for quite some time. She has had a terrible itch but it is somewhat better now. You perform a finger stick using the glucometer you brought with you (you calibrated it this am). The glucometer reading per your machine is 360; so, do you administer insulin, if so how much?

It is assumed you have washed your hands.

School of Nursing • Clinical Education & Resource Center

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